Multimodal stepwise analgesia for reducing opioid consumption after cesarean delivery

Abstract

Background: Opioid over-prescription after cesarean delivery (CD) delays postoperative recovery, interferes with breastfeeding and may prompt persistent opioid use after hospital discharge. We evaluated the effects of implementing a multimodal stepwise analgesic regimen on opioid consumption and pain scores after CD. Methods: This was a retrospective before-after study. Opioid intake (expressed as morphine milligram equivalents (MME)) and pain scores (using the 11-point numerical rating score) within 24-hours following planned cesarean delivery under spinal anesthesia without intrathecal morphine were compared before vs. after change in post-cesarean analgesia regimen. This included intensified non-opioid analgesia with quadratus lumborum block and shifting from scheduled to as-needed opioids. Mann-Whitney U test was used for statistical comparison (p < 0.05 was considered statistically significant). Results: We included 116 women: 58 in pre-intervention and 58 in post-intervention group. There was an 86% reduction in MME (median 14 (interquarile range (IQR) 14–18) mg pre-intervention vs. 2 (IQR 2–4) mg post-intervention; p < 0.001). Pain scores were statistically higher at 2 and 4 hours post-CD in the post-intervention group (1 (IQR 1–2) vs. 2 (IQR 1–3); p = 0.001, and 2 (IQR 1–3) vs. 2 (IQR 2–3); p = 0.03, respectively) but lower at 6 hours post-CD (3 (IQR 2–4) vs. 2 (IQR 2–3); p = 0.02). No statistically significant difference in pain scores at 1, 12 and 24 hours post-CD were observed. Conclusion: Multimodal stepwise analgesic regimen allowed shifting from scheduled to as-needed opioids for post-CD pain management without increase in pain scores. This resulted in significant reduction in opioid consumption after CD.